All health insurance companies require pre-authorization for certain procedures and hospital admissions. Your physician will submit the necessary clinical information to the insurance company (or third-party company, which many insurance companies utilize to review and determine such requests).
Your doctor’s office personnel will also coordinate scheduling with the providing facility – be it a hospital or a free-standing facility that specializes in performing MRIs, CT scans, and other procedures (Be mindful that these free-standing facilities almost always charge far less for such procedures than hospitals). If you do not have a straight copay or are paying toward your deductible – it could cost you hundreds, even thousands of dollars more if you utilize a hospital. In all cases – you should verify that the facility or hospital is IN NETWORK under your insurance plan.
Many insurance policies stipulate that it is YOUR RESPONSIBILITY to obtain the pre-authorization before you undergo a procedure. In fact, some insurance policies stipulate that if you fail to properly obtain the pre-authorization, it will not be responsible for the procedure and you will bear the full cost.
The need for you to verify that this has been properly done is greater now than ever before. Doctors’ offices and the facilities where the procedure is to be performed sometimes make mistakes. Although merely a mistake for them, it can be extremely costly for you. It costs them nothing to say “I’m sorry,” while you could pay hundreds or thousands of dollars for their mistake. That is little if no consolation.
You SHOULD ALWAYS verify that the proper pre-authorization has been obtained before undergoing an expensive diagnostic procedure or being admitted to a hospital. (With any type of diagnostic procedure as well as any non-emergency hospital procedure or admission, always use an IN-NETWORK provider). The negotiated rates between your insurance company and the provider are generally dramatically less than what you would otherwise pay for you to use an out-of-network provider or facility).
More to come in Part Two. Until then, Human Health Advocates wishes you good health!